Substance Use and Hispanic/Latinos, Connecticut: Implications for Work Round Table Discussion June, 2015

Introduction and Presentations Welcome Purpose Goals Roles and Responsibilities General Presentation Ground Rules Questions and Discussion Closing and Evaluation

Icebreaker Name Name of Organization Position/Role Location Why did you decide to participate on this meeting and what would you expect to gain?

Purpose Meet with stakeholders serving Hispanic and Latinos in need of substance use disorder treatment and recovery support services to gather information on how the National Hispanic and Latino ATTC can support the work and strengthen the workforce capacity.

Goals Identify available resources and needs regarding training and capacity building of culturally appropriate services for Hispanic and Latino populations requiring substance abuse treatment and recovery services. Ensure that Hispanic and Latino populations in need of substance abuse treatment and recovery services are seen as a priority among stakeholders. Broaden the Regional ATTCs scope on implementation practices and system transformation focusing on Hispanic and Latino effective and culturally competent practices.

What is the National Hispanic and Latino ATTC?

ATTC Network Model of Technology Transfer in the Innovation Process Copyright 2010 ATTC Network

Strategic Plan: Goals Serve as the national subject matter expert and key resource for the workforce providing substance abuse treatment and recovery support services in order to reduce health disparities among Hispanic and Latino populations. Develop and strengthen the workforce that provides substance abuse treatment and recovery support services to Hispanic and Latino populations throughout the United States by maintaining relevant and up-to-date information and resources to be used for the provision of training and technical assistance. Vision and Mission

Strategic Plan: Goals Identify available resources and needs. Ensure that Hispanic and Latino populations are seen as a priority. Broaden the ATTCs’ scope on implementation practices and system transformation. To develop and strengthen the skills and capabilities of the workforce. Build a collaborative and communicative relationship. Strategic Plan: Goals

These goals will be accomplished by … Building a collaborative and communicative relationship. Identifying regional differences and commonalities. Identifying training needs and assessing capacity building needs. Developing and implementing the strategic plan. These goals will be accomplished by …

Developing and disseminating educational products and trainings. Supporting the effective utilization of culturally competent practices. Promoting collaboration and maintaining effective communication. These goals will be accomplished by …

Assessment Curriculum and Education TOT Sustainability Training Factsheet- Webinars Stakeholders Workflow of Services

Substance Use and Hispanic/Latinos, Connecticut: Implications for Work Miguel A Cruz-Feliciano, PhD Associate Director June, 2015

Unnatural Causes – Becoming American Source: Unnatural Causes,

Hispanic vs. Latino Relation with Spain (territory, culture, colonization) Language (Brazilians are Latinos but not Hispanics) Identity (Caribbean and South America vs. Mexican) Inclusiveness East vs. West Preference

Operational Definition Individuals of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race (US Bureau of Census).

Percent of Hispanic Population in the United States: Trends and Projections Source: US Census Bureau. (2013) National population projections. Population as of April 1Projections for Population as of July 1

Hispanic or Latino by Origin United States, Source: US Census Bureau (2014). FactFinders, American Community Survey 3- Year Estimates

Hispanic Population – Concentration by States Arizona, California, Colorado, Florida, Illinois, New Jersey, New York, and Texas –States with more than 1 million Hispanics California, Florida, and Texas –Represents 55% of Hispanics in United States Arizona, California, Colorado, Connecticut, Florida, Idaho, Illinois, Iowa, Kansas, Massachusetts, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, Oregon, Rhode Island, Texas, Utah, Washington and Wyoming –22 States where Hispanic are the largest minority. Source: US Census Bureau. (2014, September). Hispanic Heritage Month 2014: Sept. 15-Oct. 15. Washington, DC: US Department of Commerce.

Hispanic and Latinos as Group vs. non-Hispanic Whites Younger (median age 27.8 vs years) Less educational attainment –(27% High School vs. 29%) Low median income ($21K vs. $32K) Higher poverty levels (25.6% vs. 11%) Less health insured (29% vs. 11%) Speak other language than English (38 million) Source: U.S. Census Bureau, Years American Community Survey.

Language Speak Spanish at home: 38 million –58% speak English very well One-third of all Hispanics (33%) do not speak English very well. Immigrants Latinos that speak only English or English very well –Children (5-17 years) : 70% –Adults : 32% Source: U.S. Census Bureau, Years American Community Survey.

Persons Below Poverty Level by Race and Hispanic Origin United States, 2012 Source: National Center for Health Statistics (2014). Health, United States, 2013: With special feature on prescription drugs. Hyattsville, MD.

Health Uninsured Percentage by Race/Ethnicity United States, 2013 Sources: Krogstad, J. M., & Lopez, M. H. (2014). Hispanic immigrants more likely to lack health insurance than U.S.-born. Retrieved from Smith, J. C., & Medalia, C. (2014). Health Insurance Coverage in the United States: Washington, DC: U.S. Government Printing Office.

Life Expectancy by Race and Hispanic Origin United States, 2010 Source: National Center for Health Statistics (2014). Health, United States, 2013: With special feature on prescription drugs. Hyattsville, MD Total

Why do Hispanic and Latinos live longer? Hispanic Epidemiological Paradox –Refers to the contradictory finding that indicates Hispanics in the United States tend to have significantly better health and mortality outcomes than the average population despite generally low socioeconomic status. Salmon bias or return-immigrant effect (equally represented by Hispanic group?) Healthy immigrant effect Social construct and artifact of research Cultural factors –Diet –Support network –Smoking –Identity

Birth and Fertility Rates by Race and Hispanic Origin United States, 2012 Source: National Center for Health Statistics (2014). Health, United States, 2013: With special feature on prescription drugs. Hyattsville, MD. Birth Fertility

Distribution of Hispanics by ATTC Region R1: 10.4% R2: 19.3% R3: 7.7% R4: 12.1% R6: 30.3% R7: 6.8% R8: 15.0% R10: 12.4% R9: 37.2% R5: 8.0% Source: US Census Bureau (2014). FactFinders, American Community Survey 3- Year Estimates

Distribution of Hispanic and Latinos: Connecticut N=3,583,561 (M=48.7% : F=51.3%) Total: 13.4% Puerto Rican52.8% Mexican10.6% Dominican5.4% Ecuadorian4.9% Colombian4.2% Guatemalan3.5% Peruvian3.4% Cuban2.0% Other SA/CA/Sp13.2% Source: US Census Bureau, Year American Community Survey

Distribution of Hispanic and Latinos: Connecticut Source: U.S. Census Bureau, 2010 Census Census Summary File 1, Tables P5 and P8. H/L Total: 13.4% Foreign born27.0% Spanish Language11.0% % GeographyTotalForeign born Fairfield16.9%20.3% Hartford 15.3%14.9% New Haven15.0%11.7% Windham9.6%4.9% New London8.5%8.6% Middlesex4.7%7.3% Litchfield4.5%7.1% Tolland4.3%6.9%

Distribution of Persons Below 125% Poverty Level Connecticut Source: U.S. Census Bureau, Year American Community Survey.

Distribution of Persons Health Uninsured Connecticut Source: U.S. Census Bureau, Year American Community Survey.

Substance Use Distribution by Race/Ethnicity: 2013 Source: Substance Abuse and Mental Health Services Administration [SAMHSA]. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of national findings. Rockville, MD: Author. NSDUH Series H-48, HHS Publication No. (SMA)

Abuse/Dependence of Illegal Drugs by ATTC Region R1: 10.1% R2: 19.7% R3: 4.7% R4: 7.5% R6: 27.0% R7: 4.5% R8: 13.0% R10: 9.0% R9: 32.9% R5: 7.0% Source: United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (2014). National Survey on Drug Use and Health: 2-Year R-DAS (2002 to 2003, 2004 to 2005, 2006 to 2007, 2008 to 2009, and 2010 to 2011). ICPSR Retrieved from:

Prevalence of Alcohol Abuse or Dependence in Connecticut by Years and Hispanic Origin Source: National Survey on Drug Use and Health: 2-Year R-DAS (2002 to 2003, 2004 to 2005, 2006 to 2007, 2008 to 2009, 2010 to 2011, and 2012 to 2013). Analysis ran on (11:08 AM EDT) using SDA 3.5: Tables

Prevalence of Illicit Drug Abuse or Dependence in Connecticut by Years and Hispanic Origin Source: National Survey on Drug Use and Health: 2-Year R-DAS (2002 to 2003, 2004 to 2005, 2006 to 2007, 2008 to 2009, 2010 to 2011, and 2012 to 2013). Analysis ran on (11:08 AM EDT) using SDA 3.5: Tables

Unmet Need for Substance Abuse Treatment: Hispanics Source: United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2014) National Survey on Drug Use and Health. Rockville, MD. ICPSR Retrieved from: 9.9% Received Treatment vs. 11% Overall United States

Perception of Need for Treatment Connecticut by Hispanic Origin Source: National Survey on Drug Use and Health: 2-Year R-DAS (2002 to 2003, 2004 to 2005, 2006 to 2007, 2008 to 2009, 2010 to 2011, and 2012 to 2013). Analysis ran on (11:08 AM EDT) using SDA 3.5: Tables

Lifetime Prevalence of Psychiatric Disorders by White not Latino and Latinos Source: Alegria, M., Canino, G., Shrout, P.E., Woo, M., Duan, N., Vila, D., Torres, M., Chen, C.N., & Meng, X.L. (2008). Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups. The American Journal of Psychiatry 165(3):359–369. doi: /appi.ajp

Past Month Substance Use among Hispanics by Nativity: Source: United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2013) National Survey on Drug Use and Health. Rockville, MD. ICPSR Retrieved from:

Lifetime Prevalence of Substance Use Disorders by Hispanic Subgroup and Immigration Status Source: Alegria, M., Canino, G., Shrout, P.E., Woo, M., Duan, N., Vila, D., Torres, M., Chen, C.N., & Meng, X.L. (2008). Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups. The American Journal of Psychiatry 165(3):359–369. doi: /appi.ajp Puerto Ricans Cubans Mexicans Other Latinos

Mental Illness Distribution by Race/Ethnicity: 2013 Source: Substance Abuse and Mental Health Services Administration [SAMHSA}. (2014). Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings. Rockville, MD: NSDUH Series H-49, HHS Publication No. (SMA)

Spanish Service Indicator, Substance Abuse Treatment Source: Substance Abuse and Mental Health Services Administration (2015). Behavioral Health Treatment Services Locator. Retrieved from: StateTotalSpanish Connecticut (51.6%) Massachusetts (47.2%) Rhode Island (35.2%) New Hampshire 36 8 (22.2%) Vermont 35 1 (2.9%) Maine (1.7%)

Distribution of Hispanics/Latinos receiving SA services from CT DMHAS (FY 14) 45

Treatment Admissions by Hispanic Population and ATTC Region R1: 12.4% R2: 19.0% R3: 5.5% R4: 5.8% R6: 20.2% R7: 4.8% R8: 19.1% R10: 10.2% R9: 33.2% R5: 4.9% Source: United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (2014). Treatment Episode Data Set -- Admissions (TEDS-A), ICPSR Retrieved from:

Treatment Episode Data Set-Admission Why Connecticut? Connecticut, 20.3% Massachusetts, 10.6% Rhode Island, 10.4% New Hampshire, 3.0% Vermont, 2.9% Maine, 2.2% Source: United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (2014). Treatment Episode Data Set -- Admissions (TEDS-A), ICPSR Retrieved from:

Latinos, n= 11,815 Male: 77.5% Age Median: 35 Service –Ambulatory, non Intensive: 44.1% –Ambulatory Intensive: 19.5% Referral –Individual: 44.0% –Criminal Justice: 31.9% –Alc./Drug Care Provider: 9.7% No prior TX: 25.4% Primary Substance (Heroin: 31.8%) Secondary Substance (Cocaine/Crack: 21.6%) Treatment Admission Characteristics, Connecticut 2012 Not Latinos, n= 48,123 Male: 69.1% Age Median: 33 Service –Ambulatory, non Intensive: 36.9% –Ambulatory Intensive: 21.2% Referral –Individual: 41.6% –Criminal Justice: 23.9% –Alc./Drug Care Provider: 15.2% No prior TX: 21.5% Primary Substance (Alcohol: 43.0%) Secondary Substance (Cocaine/Crack: 17.7%) Source: United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (2014). Treatment Episode Data Set -- Admissions (TEDS-A), ICPSR Retrieved from:

Latinos Substance Reported Alcohol: 40.9% Cocaine: 34.8% Marijuana: 36.6% Heroin: 39.3% IDU: 27.4% Substance Abuse Type Alcohol Only: 13.3% Other Drugs Only: 53.3% Alcohol and Other Drugs: 27.5% Health Insurance (Inf. Not Available) Treatment Admission Characteristics, Connecticut 2012 Not Latinos Substance Reported Alcohol: 54.2% Cocaine: 29.8% Marijuana: 29.6% Heroin: 32.7% IDU: 23.2% Substance Abuse Type Alcohol Only: 21.1% Other Drugs Only: 41.1% Alcohol and Other Drugs: 33.1% Health Insurance (Inf. Not Available) Source: United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (2014). Treatment Episode Data Set -- Admissions (TEDS-A), ICPSR Retrieved from:

Latinos n= 9,391 (2011) Reason –Treatment completed: 53.2% –Left against advise: 20.4% –Transferred: 10.3% –Terminated: 7.4% Treatment Discharge Characteristics, Connecticut 2011 and 2013 Source: United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (2014). Treatment Episode Data Set -- Discharges (TEDS-D), Concatenated, ICPSR Retrieved from: DMHAS EDW (2013). Not Latinos n= 40,505 Reason –Treatment completed: 52.5% –Left against advise: 18.6% –Transferred: 14.5% –Terminated: 6.4% Latinos n= 12,249 (2013) Reason –Treatment completed: 48.8% –Left against advise: 19.7% –Transferred: 13.1% –Terminated: 6.8% Not Latinos n= 52,999 Reason –Treatment completed: 48.6% –Left against advise: 16.8% –Transferred: 16.1% –Terminated: 6.5%

Implications for service Service availability Service accessibility Representation –Data, research, workforce, policy Language/Communication –Generational differences (conflict resolution) Inclusion Assessment and screening

Ground Rules Respect each other One person at a time No right or wrong answers Turn off or in vibration mode your cellphone Taking notes and recording You are the experts

Questions Based on your experience, what are the major issues/situations service providers face while working with H/L populations? Has Health Care Reform affected or influenced the way you are currently delivering treatment services? What are the skills that health and service providers should demonstrate to effectively work with H/L populations? What does the recovery culture look like for H/L in your area? What are the training needs of health and service providers to develop culturally appropriate service and treatment for H/L? What strengths can you mention from providers of your organization to deliver specific services to H/L? Is your organization currently involved with any Training Center of particular aspects of workforce development with specific orientation towards H/L? Based on what you have learned today, how the NHL ATTC and the Regional Center can be an integral part of your workforce development?

Question 1 Based on your experience, what are the major issues/situations service providers face while working with H/L populations?

Question 2 Has Health Care Reform affected or influenced the way you are currently delivering treatment services?

Question 3 What are the skills that health and service providers should demonstrate to effectively work with H/L populations?

Question 4 What does the recovery culture look like for H/L in your area?

Question 5 What are the training needs of health and service providers to develop culturally appropriate service and treatment for H/L?

Question 6 What strengths can you mention from providers of your organization to deliver specific services to H/L?

Question 7 Is your organization currently involved with any Training Center of particular aspects of workforce development with specific orientation towards H/L?

Question 8 Based on what you have learned today, how the NHL ATTC and the Regional Center can be an integral part of your workforce development?

Closing and Evaluation National Hispanic and Latino ATTC Tel Fax